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Associations Between Pressure Pain Threshold in the Neck and Postural Control in Patients with Dizziness Or Neck Pain – a Cross-Sectional Study Mari K

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Associations Between Pressure Pain Threshold in the Neck and Postural Control in Patients with Dizziness Or Neck Pain – a Cross-Sectional Study Mari K Knapstad et al. BMC Musculoskeletal Disorders (2019) 20:528 https://doi.org/10.1186/s12891-019-2922-4 RESEARCH ARTICLE Open Access Associations between pressure pain threshold in the neck and postural control in patients with dizziness or neck pain – a cross-sectional study Mari K. Knapstad1,2* , Frederik K. Goplen1,2, Tove Ask3, Jan S. Skouen4,5 and Stein Helge G. Nordahl1,2 Abstract Background: It is theorized that neck pain may cause reduced postural control due to the known physiological connection between the receptors in the cervical spine and the vestibular system. The purpose of this study was to examine whether the pressure pain threshold in the neck is associated with postural sway in patients with dizziness or neck pain. Methods: Consecutive patients with dizziness (n = 243) and neck pain (n = 129) were recruited from an otorhinolaryngological department and an outpatient spine clinic, respectively. All subjects underwent static posturography. Pressure pain thresholds were measured at four standardized points in the neck, and generalized pain was assessed using the American College of Rheumatology tender points. The relationship between postural sway and pressure pain threshold was analyzed by linear regression, and the covariates included age, sex, and generalized pain. Results: In the dizzy group, there was a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex, and generalized pain (bare platform; lower neck, p = 0.002, R2 = 0.068; upper neck, p = 0.038, R2 = 0.047; foam rubber mat; lower neck, p = 0.014, R2 = 0.085). The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain (upper neck, p = 0.15, R2 = 0.053; lower neck, p =0.002,R2 = 0.069). Neither of these relationships were present in the neck pain group. Conclusion: Our findings indicate that the pressure pain threshold in the neck is associated with postural sway in patients suffering from dizziness after adjusting for age, sex, and generalized pain, but only with closed eyes. The association was small and should be interpreted with caution. Trial registration: Trial registration: Clinicaltrial.gov NCT03531619. Retrospectively registered 22 May 2018. Keywords: Posturography, Neck pain, Dizziness * Correspondence: [email protected] 1Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway 2Department of Clinical Medicine, University of Bergen, Bergen, Norway Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Knapstad et al. BMC Musculoskeletal Disorders (2019) 20:528 Page 2 of 9 Background dizzy patients as many patients with dizziness suffer Postural control is a complex system [1] and to maintain from neck pain [19, 20]. Exploring this relationship in control, the body requires input from the vestibular, both patients with dizziness and patients with neck pain visual, and somatosensory systems. As part of the may provide information on how the degree of neck somatosensory system, the proprioceptive system in the pain influences postural control in two patient groups cervical spine is vital for fine tuning orientation and known to have altered balance. balance [2]. This proprioceptive system consists of the Self-reported pain intensity has been the most common deep cervical muscles, particularly the segmental mus- approach to pain measurement. While self-reported pain cles of the upper spine – with an abundance of muscle is indeed important, it is mediated by biopsychosocial spindles – in addition to mechanoreceptors from joints aspects [21] that can make it difficult to interpret. The and tendons. This system is important for both the pressure pain threshold (PPT) is a tool of both self-report stability and the mobility of the different regions in the but additionally a more objective technique [22]thatis neck. The cervical receptors provide afferent information used to quantify mechanical pain sensitivity [23, 24]. It is to the central nervous system on the orientation of the defined as the minimal amount of pressure that first head with respect to the rest of the body via modulation becomes on of pain [25]. of vestibular and visual afferent information [3]. Integra- The main aim of this study is to examine whether tion of symmetrical afferent input from the cervical, there is an association between PPT and postural sway vestibular, and visual systems in the vestibular nuclei in patients with dizziness and in patients with neck pain. complex is vital for normal head perception and postural As patients with pain syndromes, such as Fibromyalgia, control, and for providing responses resulting in precise have been shown to have reduced balance [26, 27] and motor commands to the eyes and body [3, 4]. Thus, it is patients rarely have isolated neck pain as it is usually a theorized that an asymmetry or disturbance of inputs part of a wider pain pattern [28], we wanted to adjust from cervical receptors might lead to a feeling of for generalized pain. Finally, we wanted to examine the imbalance or dizziness [3, 4]. The mechanism by which upper and lower regions of the cervical spine separately reduced cervical proprioception might lead to sensory due to their differences in mechanical properties and disturbances and reduced postural control is still uncer- distribution of mechanoreceptors. tain and disputed, even though the confluence of vestibular and cervical afferents in the brain is well Methods known [5]. It has, however, been proposed that pain, Design and setting either as a primary or secondary event, may lead to We conducted a prospective cross-sectional study of con- altered sensitivity of the muscle spindles and mechano- secutive outpatients examined at two clinical centers at a receptors due to ischemic or inflammatory events [6]. university hospital in Norway. The first center was an ear- Further, pain may cause maladaptive strategies and nose-throat (ENT) clinic that receives referrals from change the neck muscle coordination and reduce the general practitioners and specialists, both nationally and specificity of neck muscle activation, for instance, locally, concerning dizziness of suspected vestibular origin. through reduced activation of the deep segmental mus- The second center was an outpatient spine clinic that cles and increased activation of the superficial muscles admits patients from primary care physicians concerning [7]. Pain may also alter the cortical representation and long-lasting musculoskeletal pain either causing or threat- modulation of the cervical afferent input [8]. The rela- ening to cause work disability. tionship between altered neck proprioception and pain has been found in healthy subjects receiving injections Participants to induce neck pain [9], and animal studies have shown During a one-year period (2017–2018), we included con- that local injections, nerve blockades, and dissection of secutive patients examined in both clinics. The recruit- neck muscle in the upper cervical region, lead to de- ment is illustrated in Fig. 1. Patients with dizziness as creased balance, coordination, ataxia, and even nystag- their primary complaint (n = 243) were recruited from mus [10–12]. Lastly, both patients with chronic neck the ENT clinic. The ENT clinic also receives tertiary re- pain and whiplash-related disorders have been found to ferrals nationally and is a quaternary referral center for have reduced postural control [13], and the same has vestibular schwannomas and for divers suffering from been found in patients with dizziness of suspected cer- vestibular problems. As we wanted the study population vical origin [14–18]. The relationship has previously to be representative of secondary referrals, persons hav- been mostly studied in patients with neck pain; however, ing the latter conditions were not invited to participate it is not established whether the degree of neck pain is (based on medical records) and only locally referred pa- associated with the degree of postural control. It is also tients from western Norway were included. They were not known if neck pain influences postural control in diagnosed by an otorhinolaryngologist, and the examination Knapstad et al. BMC Musculoskeletal Disorders (2019) 20:528 Page 3 of 9 Fig. 1 Recruitment process included pure-tone audiometry, dynamic posturography, neck) and bilaterally at the anterior aspects of the inter- videonystagmography with measurements of ocular smooth transverse space at C5–C7 (lower neck). The algometer pursuit, saccades and bithermal caloric tests, a standard has been shown to be a reliable tool on these sites in dizzy ENT examination including otomicroscopy, examination of patients with intraclass correlation values of 0.82–0.90 on cranial nerves and cerebellar function as well as clinical intrarater reliability and 0.85–0.91 on test–retest reliabil- tests of postural sway, gait, and nystagmus. In addition, hos- ity. The minimal detectable change showed values from pitalized patients with acute vertigo were also excluded. 44.5 kPa – 86.1 kPa on intrarater reliability and 77.7 kPa – Patients with long-lasting (> 3 months) neck pain (n = 88.2 kPa on test–retest reliability [30]. Prior to the study, 129) as their primary complaint were recruited from the the examiners practiced applying pressure at a rate of ap- outpatient spine clinic where they were examined by a proximately 50 kPa/s.
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